The mission of Prognosis is to explore the nexus at which healthcare policy meets healthcare practice and how one affects the other. This blog makes readers more aware of the innovations taking place in healthcare delivery, financing and technology and the types of public policies that will encourage further progress.

Healthcare In Focus is a public education initiative of the HLC, created to promote a constructive dialogue about the state and future of American healthcare.

President and CEO of Premier healthcare alliance, Susan DeVore, discusses her predictions of what 2018 will bring in a Health Affairs article. Ms. DeVore, a member and former chair of the Healthcare Leadership Council, shares her optimism regarding the commitment to innovation and competition that is driving the industry towards value-based care and the increased utilization of actionable data. Her assessment of current trends focuses on how growth and changes in all healthcare sectors have an impact on providers, and further solidifies the importance of the work being done to improve access to care as well as outcomes.

The article is copied below and the original publication can be found here.

What To Watch In Health Care In 2018: Six Key Trends

At the start of 2018, the health care industry is on the cusp of more significant change. The GOP Congress has moved health care away from the center of their public policy agenda, creating more certainty and a clearer view. Of course greater certainty doesn’t mean total certainty, especially as market trends and business realities continue to shift. As providers move into 2018, we still feel confident in making some predictions as to what the future holds.

Clearer Skies Ahead, Pockets Of Turbulence

Uncertainty is expected during any major political transition, but it reached an all-time high for health care leaders in 2017. The fog has largely cleared, and 2018 will be a year of health care leaders starting to place their bets. Here’s what health care leaders see.

Instead of a sweeping set of legislative changes to the Affordable Care Act, the elimination of the individual insurance mandate is now the symbolic emblem of “repeal.” While some project that the mandate’s demise will lead to a decline in the private insurance market, it remains to be seen how the elimination will ultimately play out given the mandate’s relatively weak incentive for individuals to purchase coverage. The strong economy is causing employers to offer health coverage to compete for talent, and the probable enactment of the exchange market stabilization legislation should serve to calm the exchange market, potentially lowering premiums. Going forward, focusing on states will likely become the “replace” strategy for Republicans in 2018, with a larger number of waivers granted to experiment with programs, giving states greater control and reason to consider expanding Medicaid coverage. Health care leaders are viewing 2018 as a year of greater insurance market stability, with the number of insured Americans holding steady or possibly increasing over the latest numbers.

There is also more certainty around the movement to value-based care. Last year’s raging health care debate caused health care leaders to question the movement to alternative payment models (APMs). That momentum, however, is returning, and the experienced and more transparent leadership in the Department of Health and Human Services (HHS) by Alex Azar should provide significant reassurance to providers on both insurance market certainty and the movement to value-based care.

Health care leaders still face major financial threats. Bad debt continues to grow, reaching $38.3 billion in large part due to the rise of high-deductible health plans. Hospitals have taken $148 billion in Medicare payment cutssince 2010, and these cuts are scheduled to continue. Some states are cutting Medicaid reimbursement. 82 rural hospitals, as well as many urban hospitals, have closed since 2010. This year’s $1.6 billion cut in 340B payments will crush some of the most financially challenged hospitals treating the most vulnerable patient populations. Hospitals continue to be disadvantaged in the design of many of the Centers for Medicare and Medicaid Service (CMS)’s pay for performance and alternative payment models. As a result, hospital margins remain in low single digits, and the Medicare Payment Advisory Commission projects that the Medicare margin will fall to negative 11 percent in 2018.

Attention, Value Shoppers: The New Health Care Market

2018 will be a year of a renewed focus by CMS on paying for value, particularly with the continued ramp up of the Medicare Access and CHIP Reauthorization Act of 2015 that incents clinicians to take risk, and new APMs that create attractive alternatives for fence sitting providers.

Perhaps more notable today are private sector actions to expand and accelerate the value-based payment movement and disrupt the status quo. Given the clear signals, health care leaders are focused on gaining scale and/or vertical integration to position themselves favorably for an expansion of value-based care. Unlike past merger efforts to command greater market power, today’s consolidation is often more driven by the goal to integrate care delivery and achieve savings.

There is a new form of competition emerging. Providers and payers are organizing themselves into vertically-integrated, high-value care and financing networks. Health care leaders are actively exploring commercial, employer, and Medicare Advantage risk-based programs through either ownership models or partnerships. The most recent mega-deals by CVS and Aetna, Humana and Kindred, Ascension Health and Providence Health, Aurora Health Care and Advocate Health Care, as well as the ongoing provider acquisitions by insurance goliath UnitedHealthcare, all send a clear message: insurers, physician groups, health systems, and even retail organizations are each seeking to compete as high value care and financing networks.

The CVS/Aetna merger, for instance, is based on a strategy that they will be able to disrupt the system with a retail pharmacy and e-enabled high value provider network. The Advocate/Aurora merger is seeking to achieve regional scale by combining two of the nation’s leading clinically integrated physician networks, hospitals and other provider settings, and pharmacy capabilities in the greater Chicago-Milwaukee region. UnitedHealthcare appears to acquire more physician practices each day. We anticipate more mergers and acquisitions in 2018. As the merger and acquisition activity heats up, the question remains: Who will be best at capturing and engaging patients and customers?

Washington must be careful not to undermine this movement by confusing integration to deliver efficient, high-quality care with consolidation to reduce competition. This emerging model needs to be supported by continuing the movement by public payers to APMs and careful thought by anti-trust regulators.

Episode 2018: The Consumer Strikes Back

For providers to succeed as stewards of new care delivery networks, they need to play the game differently. This means a number of new capabilities, including creating clinically integrated physician networks, collecting and integrating data, and applying analytics to find cost, work flow, and quality improvement opportunities. It also means providing more outpatient clinics and offering additional access points, establishing preferred post-acute care networks, creating new incentive and payment arrangements, building physician measurement systems to assess performance, and negotiating successful alternative payment models with public and private payers.

To ultimately succeed, however, health leaders realize that they need to, above all else, excel at attracting and engaging patients, families, caregivers, and consumers. 2018 will be the year of focus on patient capture and engagement. Providers will work with their patients, families, and caregivers to develop approaches so they more actively manage their health and health care.

This means engaging the patient in their health and health care outcomes from the beginning. This involves providing prevention, diagnosis, and monitoring services that support the total care experience. Done well, it creates stickiness to a high value care network. Organizations are focusing more on this from a human resources training and measurement vantage point. They are also establishing patient portals, providing wearable devices, implementing patient educational programs, screenings, and pushing targeted materials to patients based on their current and anticipated needs.

For example, one of our members is providing home monitoring tools as well as tablets for video consults to help patients meet their health goals. The program focuses on total patient care from prevention to recovery. Few people leave the program, and the organization has reduced overall costs by 34 percent per year and hospitalizations by nearly 50 percent.

Financial Imperative, Meet Actionable Data

A certainty for health system leaders is the need to improve productivity and efficiency. The approach, however, is going beyond the past’s focus on reducing head count and cost of supplies.

After years of avoiding care efficiency and standardization initiatives due to the difficulty of persuading clinicians to embrace them, health care leaders now have a larger and more urgent financial imperative to identify and isolate wasteful practices, cost outliers, and the root causes for the inefficiencies. The keys to success are a strong case for change and a prioritization of efficiencies that yield both cost and quality improvements. This is, therefore, all about data and analytics.

Recent cost containment efforts we have pursued with our members provides a sense of scale. These health care systems range in size from 6 to 19 hospitals and their care transformation work has achieved savings ranging from $180 to $250 million over two years. Another specific example is a health system member of ours that realized $13 million in savings by driving care process standardization across their departments that touch just ICU and blood utilization. In addition to the savings they also improved their quality scores and reduced patient complications and readmissions. Premier data found a lot of opportunity for other hospitals around ICU stays, potentially reducing expensive ICU stays by 200,000 days across 786 hospitals. This is precisely where providers are now focusing their efforts.

2018 will be the year of delivering efficient, highly reliable care. With today’s financial imperative and actionable data, health care leaders are achieving a new level of efficiency and productivity.

America’s Other Drug Problems: Cost And Competition

Rising drug prices continue to be a dominant concern to health care leaders. Pharmaceutical innovation holds great promise for helping providers achieve their mission to improve and sustain patient lives, but it’s also a Catch-22. As providers are increasingly assuming accountability for the health outcomes of a population, six figure drug price tags and unpredictable price increases threaten financial planning and cool the enthusiasm for taking risk. 2018 will be a year of increased legislative and regulatory policymaking to foster increased drug market competition.

The FDA has and will continue to step up its game with new initiatives designed to unleash more competition that can moderate drug price trends. These include encouraging new market entrants to rapidly start developing generics in classes where there is no competition, streamlining the generic drug approval process, promoting biosimilars and taking steps to prevent branded drug makers from exploiting programs like the Risk Evaluation and Mitigation Strategy and citizens’ petitions.

Finally, manufacturers are developing new ways to demonstrate product return on investment in response to provider demands. There is increasing use of real-world evidence to demonstrate value as well as use of outcomes measures to quantify results. While value-based contracting is still in the early stages, manufacturers are looking to measure and launch these programs.

Emerging And Converging Digital Health

In every single aspect of health care, the digital revolution is making itself felt: new apps are getting patients more engaged; health sensors and wearables are creating terabytes of new, granular data, and machine learning, natural language processing, and artificial intelligence techniques and tools are all emerging new technologies. What’s more, precision medicine, telehealth, blockchain technology, and new personalized digital devices are being infused into all parts of the workflow and consumer experience.

The biggest impediment to effective use of data continues to be the lack of interoperability, especially among the electronic health records, which impedes care coordination and efficiency. While providers are waiting on HHS to implement the interoperability provisions of the 21st Century Cures Act, they are wasting no time in building data warehouses that assemble the multiple sources of data necessary to provide quality care and make informed decisions across the continuum of care. Growth of data warehouse systems and data analytics is one of the fastest growing technology areas as health systems seek actionable information to help them manage the total cost of care at a site and across sites of care.

Consequently, there is a growing and acute need for a trained workforce able to deploy, implement, and maintain health information technologies and systems and increasingly complex medical devices. Today’s electronically connected, data-and evidence-driven health care system requires staff with data science and data analysis skills. These skills are essential in gathering, interpreting, protecting, and analyzing large and complex data sets. Data management, cyber security, and governance is essential to precision medicine, value-based care and payment and population health.

These are the big trends we see impacting health care providers in 2018.

We are encouraged by the outlook. We are hopeful Congress and the Trump administration will encourage and not impede this progress to high value networks, increased competition among pharmaceutical manufacturers, and increased access to health information.

Amidst the uncertain healthcare environment Americans face, there is a threat that has remained constant: the implementation of the Independent Payment Advisory Board (IPAB). IPAB, once triggered, will impose significant cuts in the Medicare program that will affect beneficiaries’ access to healthcare. The efforts to repeal IPAB have involved almost 800 organizations across the United States that recognize the dangers of having a single entity with such unprecedented and unchecked authority.

One of the partner organizations taking a stand against this board is the Better Medicare Alliance (BMA). The BMA mission is to create a healthy future for the nation’s seniors, and ensure innovative, quality healthcare. Allyson P. Schwartz, President and Chief Executive Officer of BMA and former U.S. Representative from Pennsylvania, wrote an op-ed in The Hill that highlights the bipartisan support of IPAB repeal.

Now is a particularly difficult time to enter into any debate on health care in our country without the expectation of strong partisan divide. However, there is an opportunity that has bipartisan support and a need for action right now.

When I served in Congress, I was actively involved in the development and passage of the Affordable Care Act (ACA). I fought to be sure it met a number of goals, one of which was to reduce costs in health care through improving access to coverage, focusing on primary care, early treatment of disease, and numerous ways to encourage care to more cost effective for government and affordable for consumers.

I am proud of the important work that is the result, bringing changes right now across the country in doctors offices, hospitals, and community care to improve quality and bring down costs in Medicare.

However, not everyone was convinced that all the efforts underway now would happen or happen fast enough. To be sure costs could not grow faster than inflation, the Senate added a provision in the ACA hat many of us thought, even at the time, was the wrong way to bring down costs.

In fact, I was one of the first Democrats to publicly oppose the creation of what is called the Independent Payment Advisory Board (IPAB) and I supported Republican legislation to repeal it. IPAB repeal is now a bipartisan effort, but it has not been taken up or passed. And time is running out on a chance to stop it.

Here is how IPAB is supposed to work and why it is a bad idea.

IPAB is a board appointed by the president, with the sole authority and responsibility to cut Medicare. They are accountable to no one. If costs in Medicare rise above a certain level of inflation, cuts to bring those costs have to be made and implemented in one year. The law also says that if the President does not appoint this Board, then the Secretary of Health and Human Services has the sole discretion to make these cuts. New revenues or other actions to cover costs are not an option.

Why is this a problem for Medicare and the 55 million beneficiaries who rely on it?

Neither IPAB nor the Secretary of HHS is accountable to the voters. Given the importance of Medicare and the potential impact, our elected representatives should be involved in making this kind of major decision about Medicare. Second, the cuts have to be made in all in one year. Estimates of potentially as much as $1 billion in cuts in 2019 would mean everyone could be affected. Third, there is no requirement that the cuts be done in a way that improves care or targets waste or inefficiencies. If these cuts are across-the-board cuts, they cut important services including new innovations happening to reduce costs in the right way.

While beneficiaries are not supposed to be hurt, there could be cuts to payment to doctors or to innovative programs like telemedicine, nurse care managers, or care in the home —all of which could have a negative impact on Medicare beneficiaries.

This is not only unwise, it is unnecessary. Medicare is in the process of transitioning from the outdated and inefficient fee-for-service payment structure to one that pays for value. New payment systems are underway that focus on high-value treatments, therapies, and interventions that promote better outcomes. We should be doing all we can to drive these positive changes in Medicare, particularly for those with chronic conditions.

The success of this kind of care is evident in the achievements in Medicare Advantage, which is a public-private partnership that is driving innovations and tailored services for millions of beneficiaries through care coordination, supplemental benefits, and patient engagement.

IPAB won’t help any of this important work and is potentially destructive both to these positive efforts and to Medicare.

Congress needs to act and repeal IPAB this year.

I am proud to have built a strong bipartisan consensus on Capitol Hill to oppose IPAB. Now, as I work to strengthen the innovations in payment and care delivery that bring the promise of better, cost effective care for Medicare beneficiaries, I ask Republicans and Democrats to act on their bipartisan agreement that IPAB should not be implemented. Millions of Medicare beneficiaries will be grateful that you took action to stop this harmful and unnecessary idea from being a reality.

Allyson P. Schwartz is President and Chief Executive Officer of the Better Medicare Alliance and is a former U.S. Representative from Pennsylvania.

I had the privilege of moderating a panel at Datapalooza – the annual gathering of hundreds of leaders in health data innovation — that focused on innovations in genomic science, which are rapidly spurring discoveries in personalized medicine. Clinicians face enormous challenges in keeping pace with evolving best practices in data management and implementing these technologies into routine care. The panelists focused on how genomic sequencing could be utilized with today’s healthcare information technology infrastructure, and the most effective way to do so.

Keith Stewart, the Carlson and Nelson Endowed Director of the Center for Individualized Medicine at the Mayo Clinic, where he is also a professor of medicine at the Mayo College of Medicine, discussed the importance of understanding genomes. He said that 24 percent of people who have their genes sequenced discover new medical findings. Utilizing this information can lead to more precise treatment. Personalized treatment means that patients have the capability of finding out which drugs will give them more or fewer side effects, and which will be more effective overall. Different people react to drugs in different ways, and this advanced knowledge can significantly increase quality of life for those who would otherwise suffer from severe side effects. Dr. Stewart questioned how genome sequencing results can be stored in a way that they can be easily referenced for treatment. Mayo Clinic, he said, is working on a way to bring genomic sequencing directly to the consumer, without the need for a doctor as a middleman.

Emma Huang, associate scientific director for Janssen research and development, said that the entire health continuum — from prevention to interception to cure — can be pushed forward by genomics. Models are being developed for integrating genomic data into predictive models in real time. What the system is lacking is the deep data collection at a population level in order to predict with greater accuracy. There are currently global initiatives linking human genetics and clinical phenotypes. Ms. Huang specified that data needs depend on the stage of a patient’s health. She declared that insights from genomic data need to be available and easily interpreted by patients to achieve results.

A major implementation barrier involves data transfer, flow, and interconnectivity. Genomics data is rarely generated, analyzed, interpreted, and clinically implemented in the same system. Mark Dunnenberger, PharmD, program director of pharmacogenomics at NorthShore University HealthSystem, said genomic data needs to be integrated into the system for true value and should be used alongside clinical data. NorthShore opened the first pharmacogenomics clinic of its kind in 2015, and has recently expanded the offering with an at-home testing program, MedClueRX. Electronic health records were not built to handle the huge volume and complexity of genomic data, and the current method of saving patient information as pdf files does not provide discrete data and tends to get lost in the system. Pharmacogenomics helps clinicians choose between therapeutically equivalent treatments that benefit unique individuals in varying ways. Patients grasp the value of pharmacogenomics, Dr. Dunnenberger said, and are willing to invest money regardless of whether it is covered by insurance.

As our nation’s efforts to bring precision medicine the forefront of clinical care accelerate, we must take care to ensure we incorporate this data in ways that will be usable for clinicians and valuable for patients – without creating additional uncertainly or unsustainable costs. As is often the case, HLC members are forging a path forward for others to follow.

On January 24 at a dinner hosted by the Healthcare Leadership Council for its members, U.S. Representative Greg Walden (R-OR), the new chairman of the influential House Energy and Commerce Committee, spoke of his panel’s goals for the upcoming healthcare overhaul. CQ Roll Call published the following article based upon his prepared remarks.

Energy and Commerce Chairman Greg Walden was poised Tuesday night to outline to health care industry executives his panel’s strategy for repealing and replacing the 2010 health care law, including insights on his plans to overhaul Medicaid.

The Oregon Republican planned to use his closed-door meeting with the Healthcare Leadership Council to discuss several measures his panel would consider in the coming weeks, according to prepared remarks obtained by CQ Roll Call.

A pair of hearings to be scheduled for late next week will center on stabilizing the health insurance marketplaces and on Medicaid. Walden is working with Senate Finance Chairman Orrin G. Hatch of Utah on changes to Medicaid, which provides health insurance to more than 73 million Americans.

Walden planned to confirm during his speech Tuesday night that Republicans will model their legislation largely on a repeal bill President Barack Obama vetoed last year.

“We will use our 2015 reconciliation bill as a starting point in order to repeal major portions of Obamacare, such as the individual and employer mandates, and address the Obamacare Medicaid expansion and the failing exchanges,” Walden’s prepared remarks say. They also say a “stability period” would be included in the legislation.

Walden also is expected to say that Republicans will “maintain protections for those with pre-existing conditions” and permit children to stay on their parents’ insurance plan until age 26, two provisions in the current law (PL 111-148, PL 111-152) that President Donald Trump has voiced support for keeping in a replacement plan.

In his prepared remarks, Walden calls on the Healthcare Leadership Council to engage publicly in the health care debate. The group includes executives from hospitals, insurers, pharmaceutical companies, medical device manufactures and other industries.

“We can’t do this alone. But by working together . . . we can reach our mutual goal of helping people live healthier lives and giving every American a new opportunity to get affordable health care coverage,” Walden will say, according to the prepared remarks.

Changes to Medicaid

Walden’s remarks don’t detail how the GOP would address the 2010 law’s Medicaid expansion, but he confirmed to CQ Roll Call earlier in the day he has had several meetings with Hatch to discuss their legislation on changes to the program.

Earlier this month, Walden organized a meeting between Republican lawmakers on his panel and GOP governors to discuss potential changes to Medicaid. He also attended a separate but similar meeting organized by Senate Finance.

A top aide to Trump said earlier this week the president would propose turning Medicaid into a block grant system. Some GOP governors at the meetings last week, however, suggested a per capita approach that would explicitly require the federal government to incorporate enrollment changes when determining reimbursement rates.

J. Mario Molina, president of Molina Healthcare, told CQ Roll Call both Republican and Democratic governors are likely to push for a per capita approach because it would account for potential increases in each state’s Medicaid population.

“This is going to be a debate between the states and the federal government as to how best to continue this entitlement program while trying to rein in costs,” he said in a recent interview.

Others Republican governors, including Gov. John R. Kasich of Ohio, proposed lowering the Medicaid coverage threshold to 100 percent of the poverty level and allowing people with income above that amount to get exchange coverage. The law’s expansion provides Medicaid coverage for individuals up to 138 percent of the poverty level.

However, just as important as accelerating the approval process is ensuring that patients have access to these treatments once they become available. HLC is pleased to cosponsor an upcoming event that will look at factors that could have a profound effect on patient access to care and health system value.

The National Pharmaceutical Council is hosting a conference in Washington, D.C., on September 29 that will be dedicated to the issue of value assessment frameworks. These frameworks are being developed by various organizations to evaluate new biopharmaceutical treatments and medical technologies and determine if they add value to the health system or, conversely, if they simply add excessive costs without a commensurate improvement in patient health. These initiatives are intended to ultimately have an impact on coverage and reimbursement decisions.

HLC strongly advocates the health system’s transition from fee-for-service to pay-for-value, but we have also insisted that cost containment must be balanced with improved care quality. The development of value assessment frameworks will have a significant impact on maintaining this balance. We look forward to the September 29 forum at which these issues will be discussed in detail.